1. health and fitness
2. disease

Mechanisms linking red blood cell disorders and cardiovascular diseases
Ioana Mozos
Department of Functional Sciences, „Victor Babes” University of Medicine and Pharmacy,
Timisoara, Romania
Short title: Red blood cell disorders and cardiovascular diseases
Correspondence to:
Ioana Mozos, MD, PhD
Associate Professor
Department of Functional Sciences
T. Vladimirescu Street 14
Timisoara, Romania
e-mail: [email protected]
Abstract:The present article aims to review the main pathophysiological links between red blood
cell disorders and cardiovascular diseases, provides a brief description of the latest studies in this
area and considersimplications for clinical practice and therapy.
Anemia is associated with a special risk in pro-atherosclerotic conditions and heart disease and
became a new therapeutic target. Guidelines must be updated for the management of patients
with red blood cell disorders and cardiovascular diseases, and targets for hemoglobin level should
be established. Risc scores in several cardiovascular diseases should include red blood cell count
and RDW.
Complete blood count and hemorheological parameters represent useful, inexpensive, widely
available tools for the management and prognosis of patients with coronary heart disease, heart
failure, hypertension, arrhythmias and stroke.
Hypoxia and iron accumulation cause the most important cardiovascular effects of sickle cell
disease and thalassemia. Patients with congenital chronic hemolytic anemia undergoing
splenectomy should be monitored, considering thromboembolic and cardiovascular risk.
Keywords: Anemia, Pathophysiology, Heart failure, Coronary Heart Disease, Hypertension,
Arrhythmias, QT interval, Thalassemia, Sickle Cell Anemia, Hereditary Spherocytosis, Stroke
1. Introduction
There are several criteria enabling the diagnosis of anemia. Hemoglobin below 13 g/dL
and 12 g/dL in men and women, respectively, according to the criteria of the World Health
Organization defines anemia.
Anemia, a condition frequently associated with chronic diseases is an independent risk
factor for cardiovascular complications [1] and a 1g/dl decrease in hemoglobin level is an
independent risk factor for cardiac morbidity and mortality [2]. On the other hand, there are
several forms of congenital hemolytic anemia with cardiovascular complications.
The present article aims to review the main pathophysiological links between red blood
cell disorders and cardiovascular diseases, provides a brief description of the latest studies in this
area and considersimplications for clinical practice and therapy. The present review will enable
updating of the guidelines for the management of patients with both red cell disorders as well as
cardiovascular pathology.
2. Anemia in cardiovascular disease
Multimorbidity is common in patients with cardiovascular diseases [1]. Prognostic
markers are needed to identify patients with cardiovascular disease at high risk for adverse events
[3]. Several epidemiological studies investigated possible associations between hemorheological
profile and cardiovascular disease; hemorheological alterations may be the cause of the disorder,
but they may also result from poor tissue perfusion [4].Hemorheology is the ability of blood to
deform, and depends on the hematological characteristics able to influence blood flow
independently of the vascular wall, including plasma viscosity, hematocrit, erythrocyte
aggregation and deformation [4]. Increased white blood cell count, together with elevated plasma
fibrinogen levels and hematocrit increase the resistance to blood flow [5].
Anemia causes hypoxia due to decreased hemoglobin level, and there are several nonhemodynamic (increased erythropoietin production, decreased affinity of hemoglobin for oxygen
due to an increase in 2,3-diphosphoglycerate) and hemodynamic compensatory mechanisms [6].
The clinical and hemodinamical changes due to acute, short-lasting anemia are reversible, but
chronic anemia leads to progressive cardiac enlargement and left ventricular hypertrophy due to
volume overload[6]. Cardiovascular compensatory consequences of anemia include
tachycardia, increased cardiac output, an hyperdynamic state due to reduced blood viscosity, and
vasodilation enabling tissue perfusion. Arterial dilatation involves also the recruitment of new
vessels and formation of collaterals and arteriovenous shunts [7], hypoxic vasodilation due to
hypoxia-generated metabolites, flow- mediated vasodilatation and endothelium-derived relaxing
factor [8]. Anemia increases cardiac output, may lead to eccentric left ventricularhypertrophy,
activation of the sympathetic nervous system, stimulation of the renin angiotensinaldosterone
system, and is closely associated with chronic inflammation and increased oxidativestress[9].
Increased left ventricular performance results frompreload elevation (Frank-Starling mechanism)
and increased inotropic state related to sympathetic activity [10, 11].Tissue hypoxia and changes
in blood flow patterns due to low hemoglobin may play anatherogenic role.Cardiovascular
complications of anemia are due to worseneing of the hyperdynamic state, volume overload,
cardiac dilation, valvular failure and heart failure with increased cardiac output. Resting cardiac
output increases only when hemoglobin concentration decline to 10 g/dl or less [6].
Anemia increases morbidity and mortality in cardiovascular diseases, due to
compensatory consequences of hypoxia, such as a hyperdynamic state with increased cardiac
output, left ventricular hypertrophy and progressive cardiac enlargement, and, probably, a
proatherogenic role.
2.1. Heart failure
Congestive heart failure is uncommon in patients with anemia without heart disease, and
may occur only in cases of severe anemia with a hemoglobin of 5 g/dl or less [6]. Anemia is a
common comorbidity in patients with chronic heart failure and is associated with an increased
all-cause and cardiovascular mortality, reduced exercise capacitydue to reduced oxygen carrying
and storrage capacity, impaired quality of life, a higher risk for hospitalization[12, 13],female
gender, older age, edema, low body mass index, increased level of neurohormones, a
proinflammatory state (elevated C reactive protein and cytokines) and more comorbidities,
including hypertension, atrial fibrillation, diabetes mellitus and chronic renal failure[14]. The
increased mortality is due to comorbidities. The prevalence of anemia in heart failure patients
vary depending on the type and severity of anemia [1, 13].The reported prevalence variability (461%) is due to lack of consensus on the definition of anemia [13, 15]and due to different
exclusion criteria. Anemia is also prevalent in chronic heart faiure with preserved ejection
fraction [16, 17].
Anemia in patients with heart failure is often normochromic and normocytic, with a low
reticulocyte count[14, 18]. Vitamin B12, folic acid and iron deficiency may also cause anemia in
heart failure patients. Deficiencies in vitamin B12 or folic acid may cause megaloblastic anemia.
The cause of vitamin B12 deficiency is seldom dietary; it is more likely due to gastrectomy or
comorbidities affecting the terminal ileum. Folic acid deficiency is caused by abnormalities in
food intake, chronic alcohol abuse, parenteral nutrition and diseases of the small intestine [14].
Nutritional iron deficiencies caused by anorexia, insufficient diet supply, gastrointestinal
malabsorption and aspirin- induced gastrointestinal bleeding can cause iron deficiency [19-21].
Ferritin is an acute-phase protein, and a reduction in ferritin because of iron deficiency maybe
masked by an acute inflammatory response in some patients. Renal dysfunction, neurohormonal
activation and proinflammatory cytokines in heart failure enable the development of anemia of
chronic disease, with deffective iron utilization, inappropriate erythropoietin production and
depressed bone marrow function [19]. Impaired proliferation, differentiation, mobilization and
iron incorporation in hematopoietic stem cells contribute to the bone marrow dysfunction
[22].The decreased renal perfusion in heart failure patients causes renal hypoxia and enables the
release of erythropoietin (EPO), but the response of the bone marrow to EPO is blunted due to
the proinflammatory cytokines. The activation of the renin-angiotensin-aldosteron system due to
the decreased renal perfusion, releasesangiotensin II, which also stimulates EPO production and
bone marrow erythroid progenitor cells[23]. Iron available for erythropoiesis is reduced due to
increased proinflammatory cytokines (functional iron deficiency), which decrease ferroportin
(release of iron from macrophages), increase hepcidin (which blocks duodenal iron absorption)
and the divalent metal transporter (ableto bind and transport divalent metals along the plasmatic
membranes) [19].Proinflammatory cytokines, including tumor necrosis factor and interleukin 6
are not only increased in heart failure, but also inversely related to hemoglobin[24].Hemodilution
has also a contribution to anemia in heart failure patients. Anemia reduces blood viscosity,
decreasing systemic vascular resistance due to enhanced nitric oxide- mediated vasodialtion. Low
blood pressure causes neurohormonal activation, with increased sympathetic and reninangiotensin-aldosterone activity, impairing renal perfusion and expanding the extracellular
space[19]. Volume expansion and vasodilation increases cardiac output and oxygen transport [25,
26]. These mechanisms suggest that correction of anemia is unlikely to improve left ventricular
function [19].The use of angiotensin-converting inhibitors or angiotensin receptor blockers may
inhibit EPO synthesis [20]and prevent the breakdown of hematopoiesis inhibitor N-acetyl-serylaspartyl- lysyl-proline [27].
Anemia impairs prognosis in heart failure patients due to a reduced oxygen supply,
ventricular remodeling, the neurohumoral profile, the proinflammatory state and several
comorbidities, including renal failure and cardiac cachexia. Probably, anemia is both a mediator
and a marker of a poor outcome in heart failure [19].
Therapy includes iron, folic acid, blood transfusions and erythropoiesis-stimulating agents
(ESA). ESA may be considered as adjunctive therapy in patients with heart failure, improving
besides hemoglobin level, also left ventricular ejection fraction and functional classand reducing
diuretic doses and left ventricular remodeling [28-31].EPO also confers anti-apoptotic effects,
required for the survival of myocardial cells after ischemia [32].On the other hand,
erythropoiesis-stimulating agents may increase the risk of cardiovascular events according to
several trials [33, 34]due to impaired nitric oxide production and release [35]and the
protrombothic and antifibrinolytic effect . Iron therapy, reported to improve anemia and cardiac
function in several studies, increases oxidative stress [36, 37].Iron application is controversially
debated, but intravenous iron administration is mandatory in patients with iron deficiency,
especially if serum ferritin values are below 100μg/l [14]. Markers of inflammation should also
be considered, the optimal threshold for initiation of treatment, target hemoglobin and doses of
EPO should be standardized. The main question that requires an answer refers to the hemoglobin
level to be achieved. There exists a risk of blood pressure increase at higher Hb levels, explained
on increasedviscosity and reduced nitric oxide availability. Blood transfusions should be
considered in cases of severe anemia.
Iron deficiency, defined as depleted body iron stores (low serum hepcidine) and unmet
cellular iron requirements (high-serum soluble transferrin receptor) are common in acute
heartfailure, and is associated with poor outcome [38].
The simultaneous presence of anemia, heart faiure and chronic kidney diseases forms a
pathological traingle called cardiorenal anemia syndrome [20]. The presence of even mild
anemia and chronic kidney disease was associated with a synergistic amplificatio n of the risk of
death in patients with an old myocardial infarction, angina, heart failure, left ventricular
hypertrophy, peripheral vascular disease, previous stroke and thromboembolism [1, 39]. Chronic
kidney disease causes anemia due to several mechanisms, including inadequate erythropoietin
production, related to tubulointerstitial fibrosis and loss, and vascular obliteration [40].
The main mechanisms of anemia in patients with heart failure are: renal dysfunction,
increased sympathetic and renin-angiotensin-aldosterone activity, hemodilution, absolute or
functional iron deficiency, impaired erythropoietin production and activity, activation of the
inflammatory cascade, angiotensin converting enzyme inhibition and angiotensin receptor
blockade, vitamin B12 and folic acid deficiency (figure 1). Therapy includes iron, folic acid,
blood transfusions and erythropoiesis stimulating agents. The main question still requiring an
answer is the hemoglobin target level to be achieved in order to improve prognosis in heart
failure.
2.2. Coronary heart disease
Anemia is a known risk factor for ischemic heart disease and a frequent finding in
patients with acute coronary syndrome [41-43].Multiple factors related to red blood cells are
associated with coronary heart disease, including hemoglobin, hematocrit, RDW and erytrocyte
sedimentation rate [44]. Several studies suggest a detrimental effect of anemia in patients with
acute myocardial infarction[40, 42, 45], related to reduced oxygen content in the blood, increased
myocardial oxygen consumption due to elevated cardiac output to maintain appropriate tissue
oxygenation, bleeding episodes during invasive procedures, anticoagulation and
inflammation[43, 46, 47].A reduced oxygen transport capacity in anemia causes a compensatory
increase of the heart rate, resulting in a shorter myocardial perfusion time in diastole [40].A few
studies in disease- free subjects and patients with vascular disease showed an association between
increased hematocrit and increased risk of coronary heart disease, but low risk ratios were
observed, and, therefore, the clinical usefulness of hematocrit alone is not clear [48]. Thrombotic
events are important causes of morbidity and mortality in polycythemia vera [6]. Recent studies
showed a negative correlation between hematocrit to blood viscosity ratio and likelihood of
cardiac death in coronary heart disease patients [49].
The anemia of inflammation can reduce hemoglobin within 1-2 days, due to hemolysis of
red blood cells and a suppression of the response to erythropoiesis mediated by tumor necrosis
factor, acute changes in iron metabolism [47, 50, 51].An increased uptake of iron in the
reticuloendothelial system is responsable for the lowered Fe level, iron saturation of transferin
and total iron binding capacity [51, 52]. A reverse association was found between C reactive
protein and anemia, inflammation explaining the decline in hemoglobin[47].
The prevalence of anemia increases during hospitalization Both the admission
hemoglobin level and the subsequent fall in hemoglobin level ˃ 1.8 g/dL were associated with an
increased risk of all-cause mortality or cardiogenic shock in patients with acute coronary
syndrome [43].The main causes of anemia were blood loss, hemodilution, kidney failure and
inflammatory reactions in response to myocardial injury[42, 43]. A modest fall in hemoglobin
should have a beneficial effect due to reduction in blood viscosity, but greater falls increase
myocardial ischemia and cause a neurohormonal reaction, which are responsable for the worse
prognosis[43]. On the other hand, anemia at admission, especially associated with a history of
bleeding, restricted the use of antithrombotic therapy, orienting toward a conservative therapy
[43]. Hemoglobin is also an independent determinant of heart failure in acute coronary
syndromes [53].
Sargento et al. evaluated the prognostic value of biohemorheological profile in transmural
infarction survivors, revealing a close relationship between leukocyte count, protein C activity
and erythrocyte membrane fluidity and cardiovascular events during long term follow-up [4].
Membrane fluidity is an indicator of membrane microviscosity and lipid mobility and is
influenced by anesthetics, antiarrhythmics and insulin [54, 55].
The red cell distribution width (RDW), reflecting mean corpuscular volume
heterogeneity, is an early parameter of iron deficiency, sideroblastic, vitamin B12 and folic acid
deficiencies [21].In patiens with stable coronary artery disease, higher red cell distribution width
(RDW), an index of anisocytosis, correspond to higher comorbidity burdens (diabetes mellitus,
heart failure, atrial fibrillation, periferal vascular disease and chronic kidney disease), and is an
independent predictor of mortality [56]. The mentioned comorbidities are associated with a
proinflammatory state and oxydative stress. Oxydative stress impairs membrane fluidity of the
eritrocytes, reducing the life span of the red blood cells, and inflammation is known to block iron
metabolism and erythropoietin response.Increased RDW is associated with impaired
microvascular perfusion, causing hypoxia even in patients without anemia[56]. RDW was an
independent predictor of death in patients with a previous myocardial infarction or stroke, and of
death secondary to cardiovascular diseases [57, 58].
Arant et al investigated the relationship between hemoglobin level and adverse
cardiovascular outcomes in women with chest pain, in the absence of myocardial infarction or
congestive heart failure, reporting a higher risk of death from any caues, a higher risk of adverse
outcomes and shorter survival time free of adverse outcome, but no correlation between
hemoglobin level and presence or severity of coronary atherosclerosis [59].
It has been suggested to correct anemia in patients with coronary artery disease, if
hemoglobin levels have fallen to 9-10 g/dl in symptomatic angina[60].In severe anemia, blood
transfusions should be considered, but the data in regard to the effects of transfusions are
contradictory. Rao et al observed a increase in 30-day mortality in patients with acute coronary
events after transfusions, and no impact if the hematocrit was less than 25% [61]. Other authors
reported a beneficial effect of transfusions and an improved prognosis [62, 63].The adverse
effects of transfusions may be explained by the depletion of 2,3-diphosphoglyceric acid and nitric
oxide stored in red blood cells, impairing oxygen release by hemoglobin and endothelial function
[64]. Well designed, randomized, controlled trials of transfusion strategies are needed in order to
provide guidelines with regard to blood transfusions in patients with acute coronary syndromes
[48].
Components of the complete blood count, such as hematocrit, white blood cell count and
their subtypes are associated with coronary heart disease and can improve our ability to predict
coronary heart disease risk [48].Several possible mechanisms of the role of red blood cells in
coronary heart disease have been suggested, including viscosity, increased platelet aggregation
associated with release of adenosine diphosphate, association with elevated serum cholesterol and
triglycerides, deposition of cholesterol in the atherosclerotic plaque, stimulation of an excessive
influx of macrophages, enlargement of the atherosclerotic necrotic core, decreased fluidity of red
blood cells [48].
An imbalance between oxygen demand and supply, bleeding episodes due to invasive
procedures and anticoagulation, inflammation, hemodilution and kideny failure are the main
mechanisms linking anemia and coronary heart disease (figure 2). Red blood cell count,
hemoglobin, hematocrit and RDW should be monitored in patients with coronary heart disease.
2.3. Hype rtension
Normocytic anemia is common among hypertensive patients, with lower hemoglobin
concentrations in patients with uncontrolled than among those with well controlled hypertension,
indicating a higher cardiovascular risk in uncontrolled hypertension [65]. Patients with anemia
had higher nocturnal systolic and mean blood pressure and a tendency for increased diastolic
blood pressure and lower dipping status compared to patients with normal hemoglobin levels [66,
67].Leptin, the product of the human obesity gene, might be involved in the regulation of the
rheologic behavior of erythrocytes and the microcirculation in hypertension [68].
Anemia is associated with higher cardiovascular risk, higher blood pressure values and
lower dipping status in hypertensive patients, and hemoglobin should be monitored in
hypertensive patients.
2.4. Arrhythmias
Several electrocardiographic changes were described in patients with anemia, including
ST segment depression, T wave inversion, QT interval prolongation, reduced amplitude of the
QRS complex [69-71]. A long ECGQT intervalduration, exceeding 450 ms, is a predictor of
ventricular arrhythmias and sudden cardiac death.The pathophysiological link between anemia
and prolonged QT intervals is,probably, hypoxia and decreased myocardial oxygen supply.
Anisocytosis, an earlysign of anemia, and macrocytosis are also linked to prolonged QT intervals
in hypertensive patients [72].Positive correlations between serum ferritin or hemoglobin and QTc
were observed in non-pregnant females with severe iron deficiency anemia [73].
Zeidman et al. reported both supraventricular (sinus tachycardia, atrial premature
contractions, atrial fibrillation) and ventricular arrythmias (ventricular premature contractions,
ventricualr tachycardia, ventricular fibrillation) in patients with coronary heart disease and
anemia [41]. Patients with lower levels of hemoglobin, iron and total iron binding capacity were
more likely to develop ventricular than supraventricular arrhythmias [41].
Prolonged QT intervals and arrhythmia risk are linked to anemia, macrocytosis,
anisocytosis, serum ferritin and hemoglobin, and hypoxemia supports this links.
2.5. Stroke
Stroke is the leading cause of adult disability, the third cause of mortality, and has a high
prevalence, consdering the growth and aging of the population. Complete blood count abnormalities
represent a useful tool for stroke patients prognosis. A low hematocrit means hypoxia and
cerebral ischemia. Blood flow augmentation and turbulence due to anemia enables migration of a
thrombus and embolism [74]. Anemia was associated with an increased mortality after ischemic
and hemorrhagic stroke [75, 76]. Cardiac surgery patients, routinely hemodiluted, often sustain
perioperative cerebral infarction and at hemoglobin concentrations of 10-12 g%, increased
cerebral blood flow and oxygen extraction are sufficient to enable penumbra oxygen uptake to
remain nearly normal [99]. Penumbra oxygen extraction reserves are nearly exhausted even after
moderate anemia [77]. Several previous studies focused on the impact of a high hematocrit level
on stroke, reportet a higher stroke prevalence related to a high hematocrit level [78], because of
its contribution to cerebrovascular blood viscosity and its potential role in cerebral atherogenesis
[79, 80]. Diamond et al. found midrange hematocrit levels (45%) as having the best outcome in
stroke patients [81].
Anemia enables cerebral ischemia, blood flow turbulence, migration of a thrombus and
embolism and reduces penumbra oxygen reserves. Besides that, anemia was associated with
increased mortality after ischemic and hemorrhagic stroke.
3. Cardiovascular consequences of hereditary forms of anemia
3.1. Cardiovascular consequences of thalassemia
Thalassemia is the most common hereditary disease, a genetic blood disorder due to
reduced synthesis of beta or alpha globin chains [82, 83]. Regular transfusion therapy improves
the quality of life, but also causes iron overload [84]. Transfusion iron overload can directly
affect the heart tissue through iron deposition in the ventricular walls, causing left ventricular
systolic and diastolic dysfunction (later signs of iron overload), pulmonary hypertension,
valvulopathies, arrhythmias and pericarditis [83, 85]. Congestive heart failure is the leading cause
of morbidity and mortality, but sudden cardiac death may also occur, even in the absence of
cardiac dysfunction[82]. The degree of cardiac dysfunction depends on the quantity of iron
deposited in the myocardial fibers and the number of the affected fibers [85]. The iron is stored in
intracellular lysosomes as non-toxic ferritin and hemosiderin, but above certain concentrations,
reactive iron species are generated and the cell begins to fail [85]. Thepatchy nature of cardiac
iron deposition may provide substrates for re-entry and risk of fatalarrhythmias in patients
withbeta-thalassemia, which explains the appearance of premature ventricular contractions,
ventricular tachycardia and late ventricular potentials [86, 87].Iron toxicity arrhythmias are often
automatic, represented by polymorphic atrial and ventricular arrhythmias [84]. Bradicardia and
repolarization abnormalities on 12- lead electrocardiography including QT interval prolongation,
leftward shift of the T wave axis, generalized STT changes, are the most specific markers for iron
cardiomyopathy in thalassemia major, and may be helpful to stratify cardiac risk when cardiac
MRI is unavailable [82]. Tachycardia as physiologic compensation of anemia and strongly
associated to vascular inflammation due to iron overload, QT prolongation and intraventricular
conduction delays secondary to compensatory ventricular dilation and other myocardial stressors,
ST and T wave abnormalities, were also reported in thalassemia major, regradless of cardiac iron
status [82]. The absolute QT interval duration was a better marker of cardiac iron than heart rate
corrected QT interval because the interaction between heart rate and QT interval is impaireddue
to iron overload [82]. Impairment of delayed rectifier potassium channel and calcium channels
may explain the changes in repolarization [82, 84]. ECG recording could be used by
hematologists as a screening tool in those patients. Iron deposition, microvascular scarring
combined with inflammatory and immunogenetic factors, endocrine deficiencies, chronically
elevated cardiac output secondary to anemia, increased cardiac afterload due to accelerated
vascular aging and the hypercoagulability state are involved in the pathophysiology of cardiac
dysfunction in beta-thalassemia major[82, 83, 88, 89].Within cells, iron catalyses the production
of reactive oxigen species, causing lipid peroxidation and organelle damage [83].Atrial
mechanical depression was reported as a very early sign of cardiac damage in beta-thalassemia,
prior to diastolic and systolic left ventricular dysfunction [89]. Males and females are at the same
risk of accumulating iron in their hearts, but women better tolerate iron toxicity, probably due to a
more effective antioxidant defense, a slower metabolic rate, more active immune function,
reduction in the activity of growth hormone[90]. The cardiomyopathy may be reversible if iron
chelation therapy is given[85]. Thalassemia major patients with diabetes mellitus had a higher
risk of cardiac complications, including heart failure, hyperkinetic arrhythmias and myocardial
fibrosis[91]. A protective effect of beta-thalassemia against myocardial infarction was
demonstrated in thalassemia minor due to a favorable lipidemic, a better cardiovascular risc
factor and 24- h blood pressure profile, compared with anemic and nonanemic hypertensives [92,
93].
The survival of patients with thalassemia major has improved lately, as a result of regular
transfusions and chelation therapy and new imaging methods, which allow better management of
iron overload [90]. There also exists an increased risk of thrombosis in beta-thalassemia
intermedia and major, causing deep venous thrombosis, pulmonary hypertension and pulmonary
embolism, inversely correlated with the hemoglobin level [85]. Several biological risk factors for
thrombosis were mentioned, including splenectomy, increased levels of thrombin-antithrombin
III complex, red cell phosphatidylserine exposure, and plasma coagulation factor abnormalities
[85].
The main cardiovascular effects of thalassemia are due to hypoxia and iron
accumulation.Iron overload explains most cardiovascular problems in thalassemic patients, such
as left ventricular systolic and diastolic dysfunction, reentry ventricular arrhythmias, atrial
mechanical depression, myocardial fibrosis, vascular inflammation with early vascular aging and
hypercoagulability.
3.2. Cardiovascular consequences of sickle cell anemia
Sickle cell anemia is caused by hemoglobin S, which changes the shape of the red blood
cells from discs to sickles, reduce their deformability and enhance stickiness, leading to
obstructive adhesion of sickle cells [94]. Ischemia reperfusion injury and endothelial cell damage
results, with both infarcted and inflamed areas; obstruction and inflammation cause further
hypoxia and acidosis and further sickling[94]. Cardiovascular abnormalities are common in
sickle cell anemia, including cardiac enlargement, myocardial infarction,acute stroke, chronic
cerebral ischemia, arrhythmias, increased arterial stiffnessand microcirculation damage due to
vaso-oclusive crisis, QT interval borderline or moderate prolongation and cardiac autonomic
neuropathy[94-100].Autonomic dysfunction and QT interval duration were correlated in patients
with sickle cell anemia, suggesting significant clinical implications. The presence of hypoxia due
to chronic anemia, and cardiac autonomic neuropathy, with unopposed sympathetic activation
and abnormalities of ventricualr repolarization, predisposes to ventricular electrical instability
and increased arrhythmia risk [98]. Several foci of old and new degeneration in the sinus and
atrioventricualr node andHis bundle, fibrosis and fibromuscular dysplasia affecting small
coronary arterieswere revealed by post mortem studiesin patients with sickle cell anemia,
responsable for electriacl instability [101].Several other electrocardiographic abnormalities were
described in patients with sickle cell cardiovascular autonomic neuropathy, including increased P
wave duration, RR interval and QTc dispersion, increased frequencies of Q waves and first
degree atrio-ventricular block [102]. Only increased tricuspid regurgitant jet velocity was
significantly associated with QT interval among patients with S hemoglobinosis [99].QTc
prolongation was not associated with left ventricular hypertrophy in sickle cell anemia, and
elevated pulmonary pressure, hemolysis and acute chest syndrome may represent risk factors for
prolonged QTc[97]. QTc dispersion, the difference between maximal and minimal QT interval
duration in the 12 standard ECG leads, was also significantly increased in sickle cell disease,
especially in patients with pulmonary hypertension, correlated with regional inhomogeneity of
ventricular repolarization [103].Nitric oxide scavenging by free hemoglobin is implicated in the
pulmonary artery disease of sickle cell anemia [85].
Meloni et al compared biventricular dimensions and function using cardiovascular
magnetic resonance in pediatric, chronically- transfused patients with sickle cell disease and
thalassemia major and normal cardiac iron levels, reporting significantly greater biventricular
dilation and left ventricular hypertrophy and lower left ventricular ejection fraction in the first
group [104].
Tantawy et al investigated 50 young patients with sickle cell disease, revealing
hypercoagulability, significantly higher aortic stiffness and pulmonary artery pressure compared
to healthy controls [100]. The hypercoagulability may result from chronic hemolysis and
circulating cell-derived microparticles originating from activated platelets and erythrocytes [100].
The cell-derived particles can be considered as potential biological biomarkers for vascular
dysfunction and disease severity, beeing significantly increased in sickle cell disease patients with
pulmonary hypertension, sickling crises, acute chest syndrome, stroke, history of thrombosis or
splenectomy, and beeing positively correlated with aortic stiffness, pulmonary artery pressure and
tricuspid regurgitant velocity, and negatively correlated with aortic distensibility [100].
The main cardiovascular effects of sickle cell disease are due to the rigid erythrocytes
with hemoglobin S, impairing blood flow and enabling vaso-occlusive crises, explaining the
appearance of myocardial infarction, stroke, microcirculation damage and degeneration of the
excitoconductor system. Sickle cell anemia is also associated with other cardiovascualar
complications, such as cardiac autonomic neuropathy, arrhythmias, tricuspid regurgitation and
increased arterial stiffness. Besides disordered hemoglobin structure and function, a
prothrombotic state due to changes in the hemostatic system, such as thrombin activation,
decerased levels of anticoagulants, impaired fibrinolysis, and platelet activation are also involved
in the pathogenesis of sickle cell disease [105].
3.3.Cardiovascular consequences of hereditary spherocytosis
Hereditary spherocytosis is the most common inherited hemolytic anemia [106],
characterized by the presence of spherical-shaped erythrocytes on the peripheral blood smear,
with osmotic fragility, due to abnormalities of various erythrocyte membrane proteins, especially
spectrin and ankyrin [107]. Hemolytic, aplastic and megaloblastic crises may occur [107].
Aplastic crises appear after virally induced bone marrow suppression and may lead to severe
anemia with serious complications such as congestive heart failure [107]. Chronic anemia is well
tolerated by children, and it can rarely lead to increased cardiac output, cardiomegaly and leg
ulcers [108].
Splenectomy is recommended in patients with moderate and severe forms, considering
that it results in near complete resolution of hemolysis [106]. Persons without a functional spleen,
with hereditary or chronic hemolytic anemia, and even in those without hematological conditions,
are at increased risk of atherotrombosis, deep vein, portal and superior mesenteric vein
thrombosis, and pulmonary arterial hypertension [106, 109, 110], due to the prothrombotic state
caused by higher thrombin formation [109]. Components of the erythrocyte membrane facilitate
coagulation and the loss of the filtering function of the spleen allows abnormal red blood cells to
remain in the peripheral circulation, enabling the activation of the coagulation cascade, especially
in chronic hemolysis [109]. A prospective, cross-sectional study including patients with
hereditary spherocytosis who underwent splenectomy, revealed higher LDL-cholesterol,
fibrinogen and homocystein values, indicating a higher cardiovascular risk [106].
Anticoagulation prophylaxis and lipid lowering drugs should be considered after
splenectomy in patients with chronic hemolytic disorders, besides post-splenectomy sepsis
prophylaxis, especially if there is an additional high tromboembolic risk due to surgery or
immobilisation [110].
4.Conclusions
The presence of anemia is associated with a special risk for patients with any form of proatherosclerotic condition and heart disease. Anemia became a new therapeutic target in patients
with cardiovascular pathology, improving oxygen supply. Guidelines must be updated for the
management of patients with anemia and cardiovascular diseases, and targets for hemoglobin
level should be established, in order to improve prognosis. Early primary care diagnosis,
monitoring and management of patients with anemia and cardiovascular morbidity and evaluation
of iron, vitamin B12, folic acid and nutritional statusmay be worthwhile.On the other hand, the
unfavorable effects of therapy should also be considered, including blood pressure elevation, the
protrombotic effect and increased viscosity. Risc scores in several cardiovascular diseases should
include red blood cell count and RDW.
Complete blood count abnormalities and hemorheological parameters represent useful,
inexpensive, widely available tools for the management and prognosis of patients with coronary
heart disease, heart failure, hypertension, arrhythmias and stroke.
The main cardiovascular effects of sickle cell disease and thalassemia are due to hypoxia
and iron accumulation, respectively. Thromboembolic risk and lipid profile should be monitored
after splenectomy in patients with congenital chronic hemolytic anemia.
Conflict of Interests
The author declares that there is no conflict of interests regarding the publication of this paper.
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Table 1. Heart failure (HF) and anemia
Number of
patients
48,612
5477
528
137
20
Findings
Reference
A higher prevalence of low hemoglobin in hospitalized patients
than noted in randomized HF trials
Lower Hb is associated with higher morbidity and mortality in
hospitalized patients with HF
In patients with complicated acute myocardial infarction, anemia
on admission and/or reductions in hemoglobin are independent
risk factors for mortality and hospitalization
Anemia was more prevalent in patients with preserved left
ventricular ejection fraction (LVEF) than in those with reduced
LVEF
Anemia is common in patients with heart failure and a normal
ejection fraction and is associated with greater elevations in serum
B-type natriuretic peptide, more severe diastolic dysfunction and a
worse prognosis
Chronic heart failure is associated with profound and general bone
marrow dysfunction
Young et al,
2008 [12]
165
Iron deficiency is common in acute heart failure, and identifies
those with a poor outcome
4
In patients with edema caused by severe anemia there is salt and
water retention, reduction of renal blood flow and glomerular
filtration rate and neurohormonal activation. Patients with anemia
have a high cardiac output, a low systemic vascular resistance and
blood pressure. The low concentration of hemoglobin causes a
reduced inhibition of basal endothelium-derived relaxing factor
activity and leads to generalised vasodilation.
Therapy of anemia in congestive heart failure with erythropoietin
and intravenous iron improves cardiac and renal function, reduces
hospitalization and the need for diuretics
Erythropoietin significantly increases exercise capacity in patients
with chronic heart failure. One mechanisms of improvement in
peak oxygen consumption is increased oxygen delivery from
increased hemoglobin concentration
In anemic chronic heart failure patients, correction of anemia with
32
26
40
Anker et al,
2009 [14]
Berry et al,
2005 [16]
Brucks et al,
2004 [17]
Westenbrink
et al, 2010
[18]
Jankowska et
al, 2013 [21],
Jankowska et
al, 2014 [37]
Anand et al,
1993 [25]
Silverberg et
al, 2001 [27]
Mancini et al,
2003 [28]
Palazzuoli et
160
1432
603
40
32
erythropoietin and oral iron improves the NYHA status, measured
exercise endurance, oxygen use during exercise, renal function and
plasma B-type natriuretic peptide levels and reduces the need for
hospitalization.
Treatment with darbepoetin alfa in patients with chronic heart
failure and anemia raised Hb and improved some quality of life
indices.
The use of a target hemoglobin of 13.5 per deciliter (as compared
with 11.3 g per deciliter) was associated with increased risk of
death, hospitalizations for congestive heart failure and myocardial
infarction and no improvement in the quality of life.
Early complete correction of anemia does not reduce the risk of
cardiovascular events in patients with chronic kideny disease.
Intravenous iron therapy substantially reduced NT-proBNP and
inflammatory status in anemic patients with chronic heart failure
and moderate chronic renal failure, improving left ventricular
ejection fraction, NYHA functional class, exercise capacity, renal
function and quality of life
Intravenous iron causes a marked increase in hemoglobin in
anemic congestive heart failure patients, associated with improved
cardiac remodeling and NYHA classification.
al, 2006 [29]
Van
Veldhuisen et
al, 2007 [30]
Singh et al,
2006 [32]
Drüeke et al,
2006 [33]
Toblli et al,
2007 [35]
Usmanov et
al, 2008 [36]
Table 2. Coronary heart disease and anemia
Number of
patients
417
320
542
1,497
Findings
Reference
Anemia is a significant risk factor in ischemic heart disease
(IHD), it correlates with advanced IHD, chronic heart
failure, rhythm distrurbance and higher mortality rate.
Abnormal hemoglobin levels are common in acute
coronary syndromes. Anemia was associated with
increasing age, interventional management, adverse inhospital outcomes.
In high-risk acute coronary syndrome patients both the
admission hemoglobin level and subsequent fall in
hemoglobin level ˃ 1.8 g/dl were associated with an
increased risk of all-cause mortality or cardiogenic shock.
Anemia on admission in patients with acute myocardial
infarction treated in the acute phase with percutaneous
coronary intervention is associated with increased
mortality, especially in the subgroups with incomplete
Zeidman et al, 2004
[40]
Bindra et al, 2006
[41]
Gonzalez-Ferrer et
al, 2008 [42]
Kurek et al, 2010
[44]
32,170
1017
109
56
84
2,036
2,310
2,550
4,111
936
24,112
78,974
revascularization and multivessel disease.
A low baseline hamoglobin level is an independent
predictor of the risk of major bleeding and death in acute
coronary syndromes.
Inflammation-sensitive proteins are associated with lower
hemoglobin concentrations in acute myocardial infarction
patients.
Low hematocrit/blood viscosity ratio can be regarded as a
risk factor of cardiac death in coronary heart disease.
There was a significant reduction of plasma iron, total iron
binding capacity and plasma transferrin and a significant
elevation of serum ferritin after myocardial infarction,
changes, probably influenced by the extent of tissue
necrosis.
Serum ferritin and iron levels are increased after a
myocardial infarction due to the traumatic effect of the
infarction. An increased uptake of iron in the reticuloendothelial system for synthesis of ferritin, may account
for the lowered serum iron level and the iron saturation of
transferrin.
Total iron binding capacity is an independent negative risk
factor for myocardial infarction.
Anemia is a common comorbidity in patients with acute
coronary syndromes, and a powerful independent
determinant of left ventricular failure.
Higher red cell distribution width (RDW) values
correspond to higher comorbidity burdens and higher
mortality in patients with stable coronary artery disease.
A graded independent relation was found between higher
levels of red cell distribution width and the risk of death
and cardiovascular events in people with prior myocardial
infarction.
Lower hemoglobin levels were linked with higher risk for
adverse outcomes in women with suspected ischemia in the
absence of acute myocardial infarction or congestive heart
failure.
Blood transfusion in patients with acute coronary
syndromes is associated with higher mortality.
Blood transfusion is associated with a lower short-term
mortality rate among elderly patients with acute
Bassand et al, 2010
[45]
Steinvil et al, 2012
[46]
Kenyeres et al,
2008 [48]
Griffiths et al, 1985
[49]
Van der Schouw et
al, 1990 [50]
Magnusson et al,
1994 [51]
Archbold et al,
2006 [52]
Osadnik et al, 2013
[55]
Tonelli et al, 2008
[56]
Arant et al, 2004
[58]
Rao et al, 2004 [60]
Wu et al, 2001 [61]
39,922
myocardial infarction and a hematocrit at admission of
30%.
Anemia is a powerful and independent predictor of major
cardiovascular events in patients with acute coronary
syndromes.
Sabatine et al, 2005
[62]
Table 3. Anemia and stroke
Number of patients
480
16
774
484
3,481
5,185
6
1,012
Findings
Elevated red cell distribution width is associated
with stroke occurrence and strongly predicts both
cardiovascular and all-cause deaths in persons
with known stroke.
Bleeding and subsequent anemia may precipitate
atherothrombotic cerebral infarction.
A higher mortality rate was found in stroke
patients with anemia and the stroke risk factors of
being older than 70 years and having chronic renal
failure were more prevalent.
Anemia independently predicted mortality at 6
months and 1 year after the initial episode of
intracerebral hemorrhage.
High hematocrit may represent in women an
independent predictor of mortality after ischemic
stroke.
Risk of stroke was proportional to the blood
hemoglobin concentration.
A hypercirculatory state in patients with sickle cell
disease, accompanied by anemia and abnormal red
cells, may make patients particularly prone to
ischemic infarction.
An association exists between hematocrit level at
the time of ischemic stroke and discharge
outcome.
Reference
Ani et al, 2009 [57]
Kim et al, 2000 [74]
Huang et al, 2009
[75]
Zeng et al, 2014 [76]
Sacco et al, 2007
[78]
Kannel et al, 1972
[79]
Herold et al, 1986
[80]
Diamond et al, 2003
[81]
Figure 1.Causes of anemia in heart failure
Figure 2. Links between anemia and coronary heart disease